Incident or not?

[NurCrystal22]

So tell me what you think about this. I need advice, I was a witness to what might be considered an "incident" tell me if you think it is or what you would have done.

Patient comes for ER, has a history of CHF, ARF, he's diabetic and his chief complaint was chest pain. He's suppose to be on 2L of O2 but somehow he got hooked up to the "room air" port... thus his 02 sat dropped to 83-87 so we called the doctor, he flips out orders a bunch of labs and wants him transfered to ICU, AFTER we call we go a notice that he's connected to the wrong port, change it over and he's back to 95% so we call the doctor back and he says fine and cancels all the orders. NOW, would you say harm was done to the patient?

[CoffeeRTC, BSN, RN]

Med error? Thats an incident in my facility.

[NurCrystal22]

Med error? Thats an incident in my facility.

hmmm.. okay

[traumaRUs, MSN, APRN]

Yes, it would be an incident in my facility. However, why is the "room air" port (am unsure what this is), available in the ER. I would want to know the why of the problem.

[SmilingBluEyes]

Well said Trauma. An "incident" is worthless unless there is follow-up and problem-solving.

[unknown99, BSN, RN]

Yes, it is an incident, and could be considered a med error also. Oxygen is considered a medication in some places because it has to be ordered and it is essential to the patient's well-being.

Because it could have caused serious harm to the patient, it would have been a class-II sentinel event at the hospital where I work.

[hrtprncss]

The O2 was off and it was connected to the green wall port? Or did someone inadvertantly connect it to the yellow ''air'' port on the wall. I've known some cardiologists lose their cool when they see their patients off the oxygen and the patient is admitted for ROMI or MI. Personally, I don't know if I would write up my fellow nurse for this though. Depends on you. Tough call. Was the patient okay after you transferred the patient to ICU? How long was the patient on RA. Most importantly, you'd be working with that same nurse day after day after this incident. Is it worth writing her up? I'm playing devil's advocate...IF the patient turns out okay....personally IMHO I'd leave it be.

[button2cute]

Hello,

I would talk to the person about the incident and heck with the incident. We all make mistakes and why is there a port for room air in the er?

Just discuss it in a non-threaten way. Also, Hrt has a point....you do not want to ruin your relationship between you and her/him. Because the er is team work and you do not want people to take sides and the breakdown of the team work. I have seen it happen and it sucks over a misunderstanding.

However, you have to make the best decision for you. You can take our advice and make the decision for you.

Have a great evening,

Buttons

[sirI, MSN, APRN, NP]

Is it an incident? Yes.

Is it a med error? Yes.

Was the patient harmed? Yes.

Question is.......did the patient develop sequlae from the room air?

[austin heart, BSN, RN]

What is a "room air" port? We don't have one of these in the ER I work in.

[hrtprncss]

Could be the ports for vents...green one for 02...yellow for air...then there's also the suction...those are the three ports usually on the wall.

[Marie_LPN, RN, LPN, RN]

Incident, yes.